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Performance management of practices

Who will be responsible for performance managing practices in England in the wake of NHS reforms and what role will the quality premium play?

From April 2013, performance management of practices in England will be the role of the NHS Commissioning Board (NHSCB) under the Health and Social Care Act.

The GPC has repeatedly said that clinical commissioning groups (CCGs) should not performance managing practices when they replace PCTs next April. GPC deputy chairman Dr Richard Vautrey has told practices not to sign CCG constitutions if they contain anything related to performance management.

He says: ‘CCGs should not have a role in performance management of practices. They should be encouraging engagement, not forcing it. To do the latter would be completely counter productive.’

NHS Commissioning Board

Under the reforms, the DH will retain its functions for governing primary contracts, including negotiating with the BMA on the GMS contract, but the NHSCB will hold the contracts themselves and deal with the administrative side of them.

NHSCB national director of commissioning development Dame Barbara Hakin says that the board will hold GPs to account in a similar way to PCTs. But she warns that the NHSCB will aim to drive out variation between practices by ensuring that GPs deliver on all aspects of their contract. The board has also said that its approach to performance management of practices will be based on outcomes.

The NHSCB is due to set up a Commissioning Assembly in November to facilitate communication and sharing of best practice between CCGs. It is likely that the assembly will address the issue of performance management of practices as part of its discussions.

Local area teams

The NHSCB’s 27 local area teams look set to have delegated responsibility for performers lists and  responsible officer functions, which includes appraising GPs for revalidation.

The board is currently finalising plans for ‘standard procedures’ to support local area teams, which will include ‘performance management frameworks’. A spokeswoman says that these are expected to be published in November.

Also being drawn up by the NHSCB are ‘common operating policies’ for dealing with concerns about individual performance, managing variability in PMS contracts, local service arrangements, list cleansing, premises payments and locum and maternity payment policies.

The board is also carrying out work on ‘market management’, which will cover issues including procurement, mergers, boundaries and retirements.

New central guidance on these operational issues could mean less regional variation than is currently the case, however it is as yet unclear how detailed these new operating policies will be.

The quality premium

The primary tool the NHSCB will have at its disposal for performance managing practices will be the controversial quality premium.

In August, Dame Barbara revealed that the quality premium could be worth up to £5 per patient, which equates to £30,000 for the average practice.

She said that payment would be made to CCGs on the basis of commissioning outcomes framework (COF) attainment, as well as achieving financial balance and delivery of the NHS Constitution, which is likely to include access to general practice.

Dame Barbara also said that how quality premium funds will be made available has yet to be decided. Options include giving it to practices with or without caveats, or giving the money to CCGs. Regulations detailing the plans are due to be laid before parliament ‘over the coming months', which is expected to be in October.

Practices are unlikely to see the funding until the first quarter of the 2014/15 financial year when COF achievement is known.

The BMA opposes the quality premium because it fears it will undermine the doctor-patient relationship and leave practices open to accusations that they are not acting in the best interests of patients.

Role of CCGs

Despite the NHSCB overseeing performance management of practices, CCGs are expected to play a key role. The NHSCB says that CCGs will have a ‘statutory duty support the NHSCB to improve the quality of primary medical care’.

The DH has said that CCGs will be in a better position to challenge practice performance because they are clinically rather than managerially-led. According to the NHSCB, CCGs will be expected to:

  • provide evidence of benchmarking on primary medical care outcome indicators across member practices
  • state their commitment to openness and sharing of data/information (supported by mechanisms/framework to enable sharing).

Member practices across CCG areas are also expected to share evidence of best practice and ideas with each other. CCGs should facilitate this by having ‘clear approaches to peer review and discussions across member practices’, says the NHSCB.

GPs sitting on CCG boards will be better placed to explain any variation between practices if they are as a result of different demographics. It is hoped that GP leads and member practices will therefore be able to challenge any unrealistic targets.

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